Job Summary
This hybrid role is for a claims processing professional in health care with focus on HIPAA compliance and claims adjudication for provider and payer clients in a night shift schedule. The role involves accurate review of health care claims application of benefit rules and timely resolution of discrepancies to support high quality member and provider experiences.
Responsibilities
- Review health care claims with close attention to detail to ensure accurate capture of member demographics benefit data and provider information while working in a hybrid night shift model
- Apply claims adjudication rules to determine eligibility coverage limits and cost sharing so that claims outcomes align with payer policies and contractual agreements
- Validate claims data for completeness and consistency and raise issues promptly so that incorrect information does not lead to payment errors or delays
- Interpret benefit plans and provider contracts to calculate member and payer financial responsibility and document outcomes clearly in the system of record
- Check claims against policy exclusions benefit maximums and coordination of benefits rules to minimize overpayments underpayments and rework
- Use HIPAA compliant workflows when accessing and updating member and provider information so that privacy and security requirements are consistently met
- Research claim discrepancies by referencing benefit documents historical claims and standard operating procedures to identify root causes and propose accurate resolutions
- Collaborate with internal operations quality and configuration teams through virtual channels to clarify benefits rules and ensure consistent adjudication outcomes across cases
- Respond to queries from provider and payer stakeholders by providing clear claim status updates and explanations that support trust and reduce repeat contacts
- Track individual claim queues and turnaround time targets during night shift schedules to support timely completion of work and achievement of service level commitments
- Document all claim decisions with clear rationales to enable audit readiness improve transparency and support training for future team members
- Identify recurring claim patterns such as coding mismatches or configuration gaps and escalate them for systematic fixes that enhance first pass resolution and reduce waste
- Contribute to continuous improvement activities by sharing observations from daily claim reviews that help refine processes tools and reference materials for the wider team
Qualifications
- Demonstrate working knowledge of HIPAA guidelines and privacy expectations in handling protected health information within claims processing environments
- Show foundational experience or training in claims adjudication workflows including eligibility checks benefit application and financial calculation steps
- Exhibit familiarity with payer operations including benefit structures claim payment life cycle and expectations for accuracy and turnaround time in health care settings
- Show understanding of provider perspectives including billing practices reimbursement expectations and common sources of claim inquiries or disputes
- Apply basic data entry and validation skills with strong emphasis on numeric accuracy and consistency when working with claim amounts and codes
- Use clear written and verbal communication skills to explain claim outcomes to internal stakeholders in concise and nontechnical language
- Display adaptability to hybrid work arrangements and night shift schedules while maintaining productivity and quality in a structured operations environment
